Please enable JavaScript in your browser to complete this form.Name *FirstLastYour pronouns:Do you go by any other preferred name?PhoneEmail *Your Address: *Your age:Your birth date:Is there anything you would like me to know about your gender, gender identity, or assigned sex at birth?Is there anything you would like me to now about your cultural values?Have you experience any pregnancy or infant loss that you would like to share with me, or you think is important for me to know about?How many pregnancies have you had?What are the dates of birth of your child(ren):Have you had any vaginal births?Have you had any cesarean births? If so, were they planned or uplanned?What was the length of your pushing phase(s), if applicable and known?What were the lengths of your labour(s), if applicable and if known?Did you have any medical interventions during your birh? Epidural, forceps, vaccum, episiotomy, general anaesthetic?Did you experience an perineal tearing, internally or externally? Do you know the degree of tearing? Do you now if you had any stitching? Do you know if the stitching was done in the birthing room or the operating room?Did you experience any abnormal postpartum bleeding?About how much sleep do you get in a 24 hour period?Do you feel like you can empty your bladder fully when you pass urine?Do you have any questions or concerns about your bladder function?Do you feel like you need to 'push' to empty your bladder?How often do you feel the need to empty your bladder?How long approximately does it take to empty your bladder when you pee?(count in seconds)Do you ever have to strain to pass a bowel motion?Do you ever leak pee, poop, or wind when you laugh, jump, run, sneeze, lift something? If 'yes', do you know that it is happening when it occurs?How often do you have a bowel motion?Do you ever feel like you can't empty your bowels fully?Do you have constipation? Do you take anything to help with this?Do you ever feel any dragging, heaviness or bulginess in your vagina, pelvic floor or anus?Do you have any haemorrhoids?Do you ever experience pain or discomfort during sex or penetration?Do you ever feel like there is something pushing or falling out of your vagina or anus?Have you ever seen a pelvic floor physiotherapist?Have you recently seen a doctor, physiotherapist or another health care professional?Do you have any back or pelvic pain or discomfort?Have you ever been told that you have a pelvic organ prolapse, diastasis recti, hernia or pelvic floor concern?Do you have pain or discomfort anywhere in the body?Have you had any surgeries you would like me to know about?Are you currently physically active?Are there way you enjoy moving your body or particular physical efforts you enjoy?Do you have any physical goals?Do you enjoy the way you eat? Does if feel good?Is there anything you would like to change about the way you eat or drink?What is your relationship to food like? Is there anything you would like me to know about your relationship with food now or in the past?What is your relationship with your body and body image? Is there anything you would like me to know about your relationship with your body image in the past?What does your support system look like?Do you do career or professional work? Inside or outside the house?How much or the parenting or child rearing do you do (if applicable)?How are you managing mentally and emotionally?Have you or are you experiencing any depression during pregnancy or postpartum? To you experience any anxiety or post-traumatic stress disorder symptoms?Have you accessed any treatment or services for your mental health?Is there anything else you would like to share with me?NameSubmit
